United Healthcare and Aetna - two of the nation’s largest insurers - have withdrawn from most of the health exchanges established under the Affordable Care Act.

And they’re not the first. Years of losses on the exchanges have led many insurers to drop out.

Prior to the ACA, 18 carriers offered individual market coverage in Texas. That number will likely fall to 13 next year.

The type of coverage is also changing. Insurers initially tried to keep premiums in check by raising deductibles, but that proved insufficient. Now they are moving to narrow provider networks.

That’s not news to Texans with individual health policies. Last year Blue Cross and Blue Shield of Texas discontinued its individual market PPO plans and replaced them with HMO plans, covering only treatments provided by limited networks of doctors and hospitals.

As a result of these and other problems, enrollment in the ACA exchanges is well short of projections. The Congressional Budget Office originally estimated that 21 million people would be enrolled this year. But the Administration reports enrollment of only 11 million, as of the end of March. If the experience of the last two years holds, that figure will likely fall to about 10 million by year’s end.

The silver lining for Texas is: It could be worse. Concern over cost led policy leaders in Austin to reject the Medicaid expansion offered under the ACA. Those concerns have proved to be well-founded.

A Department of Health and Human Services report on Medicaid found that the spending on the new expansion population is running 49 percent higher than previously projected. This means that even with the federal government picking up a significant share of the costs, the costs to Texas taxpayers would have been greater than originally touted by expansion advocates. Three years ago, Heritage analysts estimated that the Medicaid expansion would cost Texas taxpayers nearly $4 billion by 2022. That number is even higher now.

Despite what proponents might suggest, there are no easy fixes for the ACA’s problems. That’s because its performance failures are the direct result of badly designed legislation, built upon the misguided philosophy that the way to improve the health care system was to subject it to even more regulation and government micro-management.

The way out of this mess is to start with a different philosophy: one that holds that patients and consumers - not government, employers or medical providers - should be the ones given more control over the money spent on health insurance and medical care.

Rather than try to standardize health insurance and medical practice, legislation based on that philosophy would remove the regulatory obstacles and special interest subsidies that currently impede innovation and competition.

It would also overhaul health care tax preferences (for employer provided insurance) and public programs (such as Medicaid) to give consumers more options and to reward them for seeking better results at better prices in health insurance and medical care - as they do in other economic sectors.

It would also mean taking a more thoughtful and balanced approach in cases where some government regulation is necessary and appropriate. For example, it would ensure that those with pre-existing conditions who have maintained health coverage would be able to change coverage when better options become available. It would also create fair rules to enable those who don’t have coverage to get coverage.

The ACA is trending in the wrong direction: Less choice, fewer options, higher premiums, low enrollment and higher than expected costs. The Obama administration has spent the last six years applying bandages to these problems, but the patient’s condition is rapidly turning critical. Whatever the makeup of the next Congress and administration, one thing is growing clearer: The next stop for the ACA will be the operating room.